July 16, Cecil County, MD Substance Abuse Assessment. Submitted to: Cecil County, MD Health Department

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1 July 16, 2013 Cecil County, MD Substance Abuse Assessment Submitted to: Cecil County, MD Health Department

2 Table of Contents EXECUTIVE SUMMARY... i INTRODUCTION... 1 Background... 1 Purpose and Goals of Cecil County Substance Abuse Assessment... 1 SUBSTANCE ABUSE CONTINUUM... 2 METHODOLOGY... 4 Review of Secondary Data... 4 Interviews and Focus Groups... 4 Youth Survey... 5 Evaluation of Current Services and Programming... 5 Limitations... 5 CECIL COUNTY, MD SOCIAL AND ECONOMIC ENVIRONMENT... 6 Age and Racial/Ethnic Composition of the Population... 6 Unemployment, Income, and Poverty... 7 Educational Attainment... 9 Housing and Homelessness Transportation Geography and Urbanicity Community Disengagement SUBSTANCE ABUSE: THE MAGNITUDE AND SEVERITY OF THE PROBLEM Use of Substances Alcohol and Tobacco Use Marijuana Use Illicit Drug Use At Risk Populations Consequences of Substance Abuse Overdose Deaths Chronic Disease Morbidity and Mortality Mental Health and Suicide Motor Vehicle Crashes Crime and Violence Sexually Transmitted Infections Teen Pregnancy Neonatal Abstinence Syndrome (NAS) RISK AND PROTECTIVE FACTORS OF SUBSTANCE ABUSE IN CECIL COUNTY Community Norms and Perception of Harm of Substance Use Stigma and Understanding of Addiction Generational Addiction Social and Commercial Access to Substances Physicians Prescribing Practices Community Resources PREVENTION SERVICES IN CECIL COUNTY Current Services School-Based Initiatives Parent and Family Education Police Initiatives Community Perceptions of Prevention Programs and Services Visibility... 45

3 Funding Quality Parent and School Involvement in Prevention Police Programs Community Recommendations for Improvement in Prevention School-Based Setting Greater Communication about Existing Resources Increased Access Multi-Organizational Partnerships TREATMENT AND RECOVERY SERVICES IN CECIL COUNTY Treatment Admission Rates Current Services Community Perceptions of Treatment and Recovery Availability of Services Challenges of Dual Diagnosis Coordination of Care Lack of Awareness of Options Cost Transportation Perceptions of Methadone and Suboxone Community Recommendations for Improvement ENFORCEMENT IN CECIL COUNTY Existing Programs and Resources Police Prescription Drug Take-Back Cecil County Drug Task Force Judicial system Community Perceptions of Enforcement Police Judicial System Community Recommendations for Improvement OVERARCHING THEMES AND RECOMENDATIONS Overarching Themes Recommendations Recommendations on Overarching Issues: Transportation, Youth Opportunities, Data Needs Recommendations on Prevention Recommendations for Treatment and Recovery Recommendations for Enforcement APPENDIX A: SECTORS/ORGANIZATIONS ENGAGED APPENDIX B: DISCUSSION GUIDES APPENDIX C: PRINCIPLES OF PREVENTION STRATEGIES APPENDIX D: PRINCIPLES OF TREATMENT STRATEGIES REFERENCES

4 Percent EXECUTIVE SUMMARY INTRODUCTION Substance abuse has a major impact on individuals, families, and communities, with effects ranging from unemployment and homelessness to mental illness and violence. Over the past decade, Cecil County, MD has experienced a significant rise in substance abuse, particularly in the area of prescription drugs and heroin, leading the local health improvement coalition to prioritize substance abuse as the county s top concern. The county has conducted a comprehensive substance abuse assessment in order to examine the key drivers of the county s substance abuse problem, current available resources, and potential evidence-based and evidence-informed practices applicable to the needs of Cecil County. This report provides an overview of the key findings of the substance abuse assessment, which explores a range of social and economic issues, health behaviors and outcomes, risk and protective factors, and available resources related to substance abuse across the continuum from prevention to treatment/recovery and enforcement. The report concludes with evidence-based and evidenceinformed recommendations tailored to the context and needs of the county. METHODS The assessment utilized a participatory, collaborative approach to look at substance abuse in its broadest context. The process included synthesizing existing data on social, economic, and health indicators in the county, program and service data from substance abuse providers, as well as information from a youth survey, 5 focus groups (35 participants) and 29 interviews with community residents and stakeholders from government, education, substance abuse treatment, social services, health care (clinicians, hospital administrators), justice system and law enforcement, local media, and recovering addicts and their families. Ultimately, the assessment engaged over 80 individuals from across the County. KEY FINDINGS The following provides a brief overview of key findings that emerged from this assessment: Cecil County Social and Economic Environment Age and Racial/Ethnic Composition: While Cecil County has seen an increase of 20,000 residents over the past 20 years, the age and racial 10.0 Maryland composition has remained steady. The county has a higher percentage Cecil County of youth under 18 (25%) than Maryland overall (23%). 4.0 Unemployment, Income, and Poverty: Cecil County was hit harder than the rest of Maryland in the 2.0 economic downturn, as shown the 0.0 Mar Mar Mar Mar Mar Mar Mar Mar figure. Unemployment rates are * 2009* 2010* especially high among the younger population, with 20-30% of year olds unemployed in Educational Attainment: Though Cecil County Public Schools were seen as strengths of the community, half of adults in the county do not receive more than a high school education. Low educational aspiration was widely reported by community stakeholders. Unemployment Rate by State and Cecil County, March 2003 March 2013 Mar 2011* *Reflects model adjustment; Source: US Bureau of Labor Statistics, Mar 2012 i Mar 2013

5 Rate per 100,000 Population Rate per 100,000 Population Housing and Homelessness: Economic challenges have created a significant population with unstable housing in the county. The homeless count was 234 people in April Transportation: Limited personal and public transportation make it difficult for Cecil County residents to access goods and services. This is of particular concern for youth and the 36% of County households with one or fewer cars. Substance Abuse Use of Substances Rates of alcohol and tobacco use are high in Cecil County, but were not mentioned as concerns among assessment participants. Many stakeholders felt that the community perceived alcohol use as socially acceptable. Stakeholders viewed marijuana use as most prevalent among young people, which is consistent with survey data that show higher rates of use among year olds (7.6%) compared to adults age 18 and older (5.7%). Illicit drug use and non-medical use of prescription drugs were higher around the County than other parts of Maryland. These use rates were consistent with stakeholder concerns about prescription opiates and, more recently, heroin. Consequences of Substance Abuse Cecil County has the highest overdose death rate in MD, as seen in the figure to the right and is one of 40 the only counties with 35 a steady increase in overdose deaths over the past two years. 20 Opioid overdoses, 15 including prescription opioids, were 10 responsible for the highest proportion of 0 overdose deaths Cecil County experiences high rates of mortality due to heart disease and cancer, though stakeholders did not mention these as concerns. The suicide rate in the county (16.9 per 100,000) is also higher than neighboring 16 counties and 12 Maryland (8.9 per ,000), as seen in 8 the figure on the right. 4 Rate of Overdose Deaths (Any Substance) per 100,000 Population, State, County, and City, Source: Maryland Department of Health and Mental Hygiene, Suicide Rate per 100,000 Population by State, County, and City, Maryland Cecil County Baltimore City Baltimore County Harford County Kent County 11.2 Maryland Cecil County Baltimore City Baltimore County Harford County Source: Vital Statistics, Cecil County, MD Substance Abuse Assessment ii

6 Both property and violent crime rates in the county have risen over the past 10 years, a trend opposite to what was seen in other counties and Maryland overall. Cecil County has a high rate of non-fatal child maltreatment cases reported to social services, 10.5 cases per 1,000 children, which is more than double the rate in Maryland (5 per 1,000). Risk and Protective Factors for Substance Abuse in Cecil County Risk factors can increase a person s chances for substance abuse, while protective factors can reduce the risk. The following section highlights several factors identified by stakeholders in Cecil County. Community Norms and Perception of Harm from Substance Abuse: Qualitative data indicate that the community perceives substance abuse as normal and acceptable as well as a low risk associated with alcohol and marijuana. These views cut across all ages and socioeconomic levels in the county. Stigma and Understanding of Addiction: Cecil County is divided in its understanding of addiction and awareness of substance abuse as a community issue. Stigma and lack of understanding of addiction was seen as preventing the community from openly discussing addiction and discouraging individuals with addiction to seek treatment. Generational Addiction: Substance abuse is a generational issue for many in the county. Children grow up in households with parents using substances every day and, as such, know no other life. Social and Commercial Access to Substances: Easy access to substances from families, friends, physicians, and commercial outlets is a driver for substance abuse in the county. Community Resources: Many stakeholders see Cecil County as having strong social services and a collaborative spirit among agencies. Perceptions of availability and access to services vary, with stakeholders citing lack of youth activities and services, funding, and transportation as barriers. Programs and Services across the Substance Abuse Continuum Prevention Services Existing Services: There are several programs in Cecil County that aim to prevent substance abuse directly and indirectly. These happen through three avenues schools, parent/family education, and police initiatives and include such programs as DARE and prescription drug take-back days. Community Perceptions of Prevention Services: In general, stakeholders were not very aware of what prevention resources exist in Cecil County. Funding was seen as a challenge, with stakeholders perceiving that prevention money had been funneled to treatment services, and current prevention funds were not enough for broad reach in the schools and community. Finally, parent and school involvement were seen as challenges to effective, broad-reaching prevention services. Treatment and Recovery Services Existing Services: Most substance abuse services in the county are related to treatment and recovery and range from counseling and support groups to pharmacotherapy. Community Perceptions of Treatment and Recovery Services: While there are many treatment and recovery resources in the county, there were several gaps and challenges noted by stakeholders, including: availability of services, barriers to accessing services (e.g., awareness of services, cost, and transportation), and coordination of care. Overall, there is a need for a coordinated, comprehensive set of core and wraparound services to make Cecil County conducive to recovery from addiction. Enforcement Programs and Resources Existing Programs: The police and judicial system provide several resources related to substance abuse, such as the Cecil County Drug Task Force, Detention Center and Re-entry Program, and Adult Drug Court. Community Perceptions of Enforcement: Stakeholders recognized lack of funding for enforcement; police are overstretched and understaffed, creating challenges to covering the county s large Cecil County, MD Substance Abuse Assessment iii

7 geography. Stakeholders also perceived limited understanding of addiction among police and the judicial system. Overarching Themes Several overarching issues emerge from the data that have been particularly challenging to Cecil County in addressing the substance abuse problem and provide important context for the discussion of future directions and the implementation of evidence-based strategies. Cecil County has been disproportionately affected in the recent economic downturn, decreasing employment opportunities and increasing negative coping behaviors, such as substance abuse. Related to the economic downturn is the scarcity of funding available for public health, social service, and enforcement services and programs. There was a strong sense that Cecil County was left out of state budget discussions and unduly scaled back in its funding for services. Two key themes related to community culture emerged from the data. First, attitudes about substance abuse were at two ends of the spectrum either substance abuse was accepted as the norm, or substance abuse was not a pervasive issue in the county and only impacted a small handful of disaffected youth. Second, substance abuse was perceived not as a disease, but a personal choice, and one where the individual and family were responsible, not the community. Cecil County has numerous treatment-related services, but they are not necessarily coordinated and do not provide the breadth of activities for a comprehensive treatment model, though there are opportunities for increased coordination of care and promotion of existing services. There was strong momentum for a large-scale coalition involving leaders, providers, and community residents themselves including parents, youth, individuals in recovery, and families of those dealing with addiction to help implement community-focused action steps. RECOMMENDATIONS Below are recommended evidence-based approaches, strategies and initiatives along the substance abuse continuum prevention, treatment/recovery, and enforcement and for overarching issues. Recommendations on Overarching Issues: Transportation, Youth Opportunities, Data Needs Three issues were identified through the assessment that permeated all aspects of the substance abuse issues in Cecil County, from prevention to treatment and recovery: Transportation: Those without a car particularly those who live outside of Elkton have difficulty accessing many services or activities in the county. One strategy is to consider alternative transportation models for those who need to get to substance abuse services (e.g., the Independent Transportation Network [ITN America] Youth Opportunities: A frequent theme in interviews and focus groups was that there were few recreational activities for young people in the County, leading to boredom and increased involvement in drugs. One solution is to focus on after-school workforce development training programs for youth. Systematic Data Collection: Current data on substance abuse will be needed to apply for funding, both to provide a description of the need and to evaluate the strategies implemented. It is important to develop a collaborative system of data collection, with all participants using similar reporting formats. Recommendations on Prevention Prevention involves taking action before a problem arises to avoid it entirely, rather than treating or alleviating its consequences. Further, prevention efforts should generally be aimed at populations and their environments (e.g., through policies and changing community norms), not just at individuals. Below are selected examples of evidence-based strategies, listed by domain (levels of influence), which may provide appropriate support to the community. Cecil County, MD Substance Abuse Assessment iv

8 Prevention Domains Individual/Peer: Prevention in the individual and peer domains comprise building personal and social skills, providing positive alternatives, communicating peer norms, and involving individuals in strategy development and implementation. Family: Prevention in the family domain involves developing parenting skills, emphasizing family interaction and bonding, and building family communication systems. School: Prevention in the school domain involves applying personal and social skills through interactive, educational approaches, providing positive alternatives, emphasizing youthparent-school collaboration, and developing school alcohol, tobacco, and other drug policies. Community/Society: Prevention in the community and society domains comprise modifying the environment, changing community attitudes and norms, adopting and advocating for policies, and organizing communities and building coalitions. Individual/Peer Domains LifeSkills Training is a school-based program that aims to prevent alcohol, tobacco, and marijuana use and violence by targeting multiple risk and protective factors and teaching personal and social skills that build resilience and help youth resist pro-drug influences. o In Cecil County, Project Crossroad is already implementing the LifeSkills Training curriculum with some of their clientele, but that is just reaching a small percentage of the youth in the county. If it was implemented within the schools, all youth would have an opportunity to benefit from the skills. Family Domain Strengthening Families Program (SFP) is a family skills training program designed to increase resilience and reduce risk factors for behavioral, emotional, academic, and social issues in children in pre-school to early high school (3-16 years old). It includes three life-skills courses (14 weekly, 2-hour sessions), one for parents, one for children or youth, and one for the families together. o In Cecil County, starting to use SFP with families that have young children (pre-school and elementary), especially those identified as needing stronger parenting skills, would provide a solid foundation for those children. This approach would aim to enhance life skills, encourage a more stable home environment, and facilitate changing the community norm to be less accepting and supporting of substance use. Given the multiple risk and protective factors addressed by SFP, it may be an appropriate family-based approach for Cecil County organizations to promote. School Domain Caring School Community (CSC) is a family-plus-school program to reduce risk and bolster protective factors among elementary school children, designed to create a caring school environment that promotes pro-social values; increases academic motivation and achievement; and prevents drug use, violence, and delinquency. o Implementing CSC across the elementary schools in Cecil County would be a way to promote a healthy school climate and support children as they develop and gain skills to make healthy decisions. This may be an important approach given that schools can be key places for children to build resiliency through the development of protective factors (e.g., caring relationships). If the budget does not allow for implementation in all 17 elementary schools at one time, the program could be phased in (e.g., over three years) across schools. Community/Society Domain Community Coalition Development Working together toward a common goal, coalitions can discover answers to many of their community s problems and serve as a catalyst to mobilize the community to help change programs, policies, and practices that contribute to substance abuse. o In Cecil County, the Drug and Alcohol Abuse Council could serve as a solid foundation for a larger community-wide coalition, since many stakeholders from other sectors are already involved in the council. Cecil County, MD Substance Abuse Assessment v

9 Expanding the council or a similar entity to include representatives of additional sectors (e.g., engaged individuals in recovery, youth, faith communities, businesses, etc.) would strengthen it and obtain greater buy-in for strategies implemented by the coalition. It would also provide a collaborative opportunity to engage youth, police, schools, parents, and others on an issue. Opioid Overdose Prevention Use and consequences of opioids are of particular concern in Cecil County. While prevention is usually focused on individuals who have not started using or become chemically dependent on drugs, opioid overdose prevention usually involves keeping people alive who are opioid dependent long enough for them to reach the point where they realize that sobriety is what they want and are then ready for treatment. Strategies include: Pre-event strategies: o Provide overdose prevention education to family and bystanders o Train healthcare professionals on educational strategies and referral services o Prescription Drug Monitoring Program During-event strategies: o Provide training on overdose recognition and response o Reduce barriers to calling 911 o Narcan/Naloxone training and distribution Post-event strategies: o Brief motivational interviewing o o Provide treatment information, referrals, and linkages to services Provide incarcerates with opiate-use history with referrals to community treatment upon release Cecil County has developed a draft opiate overdose prevention plan that includes many of these strategies. Recommendations for Treatment and Recovery The most effective substance abuse treatment is usually a long-term process which, because of the many facets of addiction and causes of relapse, requires a combination of therapies and other supportive services to meet individuals varied needs. Below are descriptions of evidence-based approaches in Assessment, Detoxification, Pharmacotherapies, Behavioral Therapies, and Recovery. In these areas, evidence-based strategies tend to be more general approaches, not specific curricula or self-contained programs. One recommendation that was consistently mentioned by study respondents was the need for an inpatient treatment facility within Cecil County, so clients can be near their families or other potential support systems. A realistic possibility for this might be to work with an existing health care facility, such as Union Hospital, to establish a partial hospitalization for short-term treatment, followed by an established aftercare plan and step-down program, with referrals to other providers in the area for counseling or other treatment modalities. Cecil County, MD Substance Abuse Assessment vi

10 Assessment In Screening, Brief Intervention, and Referral to Treatment (SBIRT) all patients in participating emergency rooms, primary health clinics, campus health centers, or other health care venues automatically undergo a quick screening to assess their alcohol and drug use; receive a brief intervention that focuses on raising their awareness of substance abuse and motivating them to change their behavior, if they are at risk; and receive referrals for more extensive treatment, if needed. Detoxification Detoxification does not constitute substance abuse treatment, but is one part of a continuum of care for substance-related disorders. Effective detox includes not only the medical stabilization of the patient and the safe and humane withdrawal from drugs, including alcohol, but also entry into appropriate treatment. There was high demand among stakeholders for this type of service in Cecil County. Pharmacotherapies Medication-Assisted Treatment refers to treatment for a substance use disorder that includes use of medications as part of a comprehensive substance abuse treatment plan with aimed at patient recovery with full social function. Evidence-based pharmacotherapies include methadone maintenance and buprenorphine/suboxone detox and/or maintenance for opioids, naltrexone for opioid and alcohol, and acamprosate and disulfiram (Antabuse) for alcohol addiction. Several of these treatments exist in the county and are most effective when combined with counseling and other wraparound services. Behavioral Therapies Behavioral therapies use basic learning techniques to modify detrimental behavior patterns by substituting new responses to given stimuli for undesirable ones. Evidence-based behavioral therapies include Cognitive-Behavioral Therapy (for alcohol, marijuana, cocaine, methamphetamine, nicotine); Contingency Management (for alcohol, stimulants, opioids, marijuana, and nicotine); Community Reinforcement Approach Plus Vouchers (primarily cocaine and alcohol); Motivational Interviewing (any drug); Twelve Step Facilitation Therapy (alcohol and other drugs) Behavioral Couples Therapy for Alcoholism and Drug Abuse; and Multidimensional Family Therapy (for youth addiction to any drugs). Many providers in Cecil County currently provide behavioral therapy; for maximum effectiveness, these therapies should include family members and be provided when clients are receiving pharmacotherapy. Recovery Halfway houses, recovery coaching, and a recovery high school are applicable evidence-based recovery strategies for Cecil County. Recovery Coaching is a form of peer-based recovery support that involves an ongoing process of giving and receiving nonprofessional, non-clinical assistance to achieve long-term recovery from severe substance abuse problems. People who have been through addiction and are in recovery themselves assist others in accessing a broad range of support services (e.g., health care, housing). o In Cecil County, the Health Department already employs recovery coaches, called Peer Recovery Advocates, to connect with service recipients in their natural environment in several areas of the community. These Advocates provide information and navigation assistance to community members who are seeking treatment and recovery, as well as related community services and resources. Additional recovery services have been called for by several community leaders and providers, especially those that address both the individual and their family. Cecil County, MD Substance Abuse Assessment vii

11 Co-Occurring Disorders Integrated treatment combines substance abuse and mental health interventions to treat the whole person with co-occurring disorders more effectively. Motivational Interviewing and Cognitive Behavioral Therapy have been modified for use with clients with COD, and two outpatient models from the mental health field, Assertive Community Treatment and Intensive Case Management, have been valuable for outpatient clients with both substance use and serious mental disorders. o In Cecil County, a theme emerging from many interviews and focus groups was frustration with the lack of treatment services for people with co-morbidities of substance abuse and mental health issues. Barriers identified were the need for cross-training staff in mental health and substance abuse treatment and difficulties integrating services with separate funding streams. Recommendations for Enforcement Law enforcement strategies are crucial to decreasing the availability of illicit drugs and alcohol. Four strategies that have been studied and have shown success in addressing drugs and related crimes are Community Policing, Problem-Oriented Policing, Collaboration with Other Law Enforcement and Community Agencies in Bordering Areas, and Restorative Justice. Community Policing involves three main components, community partnerships, organizational transformation, and problem solving, built around community police officers whose mission is to serve as liaisons between the community and the police. o In Cecil County, funding for enforcement activities is a significant challenge. Police and the court system are incredibly challenged due to the rising substance abuse problem and their lack of funding; while adopting entire programs may not be realistic, considering strategies that are new approaches to current work and do not require more staff may be possible. For example, Community Policing is an organizational shift to a proactive way of addressing issues that lead to crime, including substance abuse and related crimes. Without sufficient staffing, it may be a difficult transformation; however, there may be funding available through the Community Oriented Policing Services office from the Department of Justice. Increased communication and collaboration between police and community members would likely provide positive results. Numerous services, agencies, and organizations are currently working in Cecil County to try to address the substance abuse problem. Overall, participants in this assessment are hopeful for the future and foresee the entire community engaged in moving forward in an innovative, collaborative, and comprehensive approach toward addressing substance abuse, its causes, and consequences. Cecil County, MD Substance Abuse Assessment viii

12 INTRODUCTION CECIL COUNTY, MD SUBSTANCE ABUSE ASSESSMENT Background Substance abuse has a major impact on individuals, families, and communities. i As noted by Healthy People 2020, the effects of substance abuse are cumulative, significantly contributing to costly social, physical, mental, and public health problems, including teen pregnancy, HIV/AIDS, crime and violence, motor vehicle crashes, suicide, and other concerns. Substance abuse is also one of the most complex health issues to address, given the complicated interplay between addiction, individual behavior, family and community environment, social attitudes, and the political and legal response to substance abuserelated issues. Over the past decade, Cecil County, MD has experienced a major rise in substance abuse, particularly in the area of prescription drugs and heroin. Concerns over homelessness, a diminishing workforce and limited economic development, and a new local ordinance limiting where methadone and other clinics can be located have increased. Furthermore, Cecil County s local health improvement coalition (LHIC) recently identified four top health priorities needing action: 1) Substance Abuse Prescription Drugs/Pain Management; 2) Mental/Behavioral Health Access to Treatment; 3) Substance Abuse Prevention; and 4) Child Maltreatment. Purpose and Goals of Cecil County Substance Abuse Assessment The experience of the County and local planning processes have culminated in broad-based interest among public health, health care, business, law enforcement, and government leaders to examine the key drivers of the County s substance abuse problem, current available resources, and potential evidence-based and evidence-informed ii practices applicable to the needs of Cecil County. The County has aimed to conduct a comprehensive review of the substance abuse continuum to inform and guide the local health improvement coalition on this issue over the next several years. To this end, in December 2012, the Cecil County Health Department, in collaboration with local partners, hired Health Resources in Action (HRiA), a non-profit public health organization, to conduct a comprehensive substance abuse assessment study of Cecil County across the substance abuse continuum. This report includes the findings from this study and aims to cover several goals: 1. Provide a portrait of the current situation in Cecil County around substance use and abuse by reviewing existing data, 2. Identify the perceptions, successes, and challenges to addressing the substance abuse problem by eliciting feedback from community leaders, providers, and residents on these issues, 3. Assess the current array of services across the substance abuse continuum to understand how they are or are not currently meeting the County s needs, and 4. Recommend potential strategies, approaches, or next steps that are relevant to the County and informed by the larger substance abuse literature. i Substance abuse refers to a set of related conditions associated with the consumption of mind- and behavioraltering substances that have negative behavioral and health outcomes ii Evidence-based and evidence-informed practices refer to a set of activities that evaluation research has shown to be effective Cecil County, MD Substance Abuse Assessment 1 June 2013

13 The next section of this report discusses more in detail what is meant by the substance abuse continuum and provides a broad-based framework for considering these issues. Subsequent sections include the detailed methods used for gathering data for this study, the study s findings, and recommendations of evidence-based approaches. SUBSTANCE ABUSE CONTINUUM Substance abuse is viewed as a continuum from prevention through recovery. As with all continuums, the boundaries are not always clearly drawn. While different agencies include various domains within the substance abuse continuum, for purposes of the Cecil County substance abuse assessment, Figure 1 shows areas of the continuum that are the focus of this study. However, in many instances, treatment and recovery/maintenance are discussed within the same sections. Figure 1: Substance Abuse Continuum Prevention/Promotion- strategies intended to reduce the risk of a problem and create environments that support health. Two main areas of prevention include primary prevention (prevent use/abuse of substances) and secondary prevention (prevent abuse/consequences once use has started). Treatment - services for people diagnosed with a substance abuse problem. Treatment can occur in a variety of settings, take many different forms, and last for different lengths of time. Recovery/Maintainance - services to support individuals' compliance with long-term treatment and health. The goal of recovery and continuing care is to support the person's abstinence from drugs through prevention of relapse. Enforcement - strategies to enforce existing laws and regulations. Illicit drug and alcohol-related crime includes a broad range of illegal activity, and the myriad criminal offenses related to substance abuse may require various approaches. A comprehensive substance abuse continuum combines many programs, policies and practices, in order to reduce substance abuse in communities. A local continuum of care may include local services ranging from prenatal parenting classes, youth outreach programs in schools, outpatient and residential treatment, and community-based relapse prevention and ongoing recovery support services. Although the continuum may appear to be a sequential process, in fact, an individual may enter or leave at any point. 1 As discussed in this report, substance abuse is a complex issue that is affected by multiple factors at multiple levels individual, family, community, and society. As such some factors serve as risk factors (characteristics that precede or are associated with a higher likelihood of the problem) and some factors are protective factors (characteristics that are associated with a lower likelihood of the problem or that reduce the negative impact of a risk factor on the problem). Figure 2 provides an overview of how the larger public health field presents prominent substance abuse risk and protective factors within multiple contexts or domains. Cecil County, MD Substance Abuse Assessment 2

14 Figure 2: The Multiple Contexts of Substance Abuse Risk and Protective Factors Source: Substance Abuse and Mental Health Services Administration (SAMHSA), Prevention Training and Technical Assistance. This report aims to examine many of these risk and protective factors within Cecil County to understand the current problem and where there may be opportunities to reduce risk factors, leverage those that are protective, and foster a community and cultural environment that promotes health and well-being. Cecil County, MD Substance Abuse Assessment 3

15 METHODOLOGY A mixed-methods approach was used for the comprehensive substance abuse assessment study in Cecil County. This included a thorough review of existing secondary data, interviews with leaders and organizational staff across a range of sectors, and focus groups with providers of services in Cecil County, as well as residents who are primary recipients of services in Cecil County. Combined, these data sources aimed to provide insight into the root causes of substance abuse in the County, current successes and challenges across the continuum, and opportunities for addressing these issues. This section provides a more detailed description of the data collection methods used in this study. Review of Secondary Data Existing data on substance use and abuse and related factors were reviewed to understand the magnitude and severity of the problem within the County. In addition, data on social and economic factors such as housing, employment, and educational opportunities the social determinants of health were reviewed to provide context and help identify how these broader social and economic issues affect the community s rates of substance abuse. HRiA began by collaborating with the Maryland Department of Health and Mental Hygiene and the Cecil County Health Department to identify available local and state data sources. To profile the population s needs, multiple sources were reviewed, including Cecil County Community Health Survey data, the Local Health Action Plan, and state data from the Maryland Alcohol and Drug Abuse Administration, county data provided by national sources such as Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration, U.S. Census, and County Health Rankings. Cecil County indicators were compared to neighboring Maryland counties, statewide data for Maryland, and other appropriate benchmarks. Interviews and Focus Groups HRiA conducted interviews and focus groups with a wide cross-section of individuals in the County, including representatives from all of the sectors involved in substance abuse services: prevention, treatment, recovery, and enforcement. These types of conversations not only collect critical information on the why and how behind the data, but also identify the current level of readiness and political will for future strategies for action. In total, 29 interviews and 5 focus groups were conducted with individuals from across Cecil County. Interviews were conducted with 29 individuals representing a range of sectors. These included government officials, educational leaders, substance abuse treatment providers, other social service providers, health care providers (clinicians, hospital administrators), representatives from the justice system, and representatives from local media. In addition, five focus groups with a total of 35 individuals were held with recovering addicts, parents and family of users, front-line organizational staff providing services, and law enforcement officials. A total of 64 individuals participated in the focus groups and interviews. A full list of the different sectors/organizations engaged during the focus group and interview process can be found in Appendix A. Focus group and interview discussions explored perceptions of the substance abuse situation in Cecil County, the community s needs and strengths, challenges and successes of addressing these issues in Cecil County, and perceived opportunities to address these needs in the future. A semi-structured guide was used across all discussions to ensure consistency in the topics covered. Each focus group and interview was facilitated by a trained moderator, and detailed notes were taken during conversations. Cecil County, MD Substance Abuse Assessment 4

16 On average, interview and focus group discussions lasted minutes. The interview and focus group guides can be found in Appendix B. Youth Survey To ensure that youth experiences and perspectives were included in the study, a brief 8-question survey was developed for youth to elicit their feedback on the substance abuse issues in the County and their suggestions for addressing these issues. Administered through Survey Monkey and marketed through the Cecil County Health Department, the survey collected the perceptions of 21 youth ages in Cecil County on a range of substance abuse issues. Questions included, but were not limited to, youth perception of risk associated with different substances, perception of the prevalence of peer and adult substance use, and perception of the ease of access to different substances. Evaluation of Current Services and Programming During the needs assessment process, key substance abuse issues emerged as priorities. To help inform the recommendations and strategies for effective interventions, a review of the current substance abuse-related programming and services available across Cecil County was conducted. Aggregated data were requested from all treatment services for the number of participants in their various services, any follow-up or outcome data they collected, and any client satisfaction data collected. Only 5 services provided data via this request. Additional data on programs and services were gathered through organizational reports and websites, and during the interviews with providers themselves. Limitations As with all data collection efforts, there are several limitations related to the assessment s methods that should be acknowledged. It should be noted that for the secondary data analyses, in several instances, data were only available for the Northeast region, and not specifically for Cecil County. In many cases, no data on a specific topic were available at all, providing a significant challenge for understanding the situation and providing a baseline measurement for future work. For example, a request was made to all treatment providers in the County to provide aggregate data on reach and types of programs as well as client satisfaction and outcomes. Only a few providers responded to this request even after repeated communication efforts. Additionally, there is a time lag for many large data surveillance systems such as Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey on health behaviors, so data are not necessarily current for many indicators. Finally, youth-specific data were largely not available, the reason for which the youth survey was conducted. The small sample size and non-random sampling method of the youth survey are also limitations of this specific data collection method. Data based on self-reports should be interpreted with particular caution. In some instances, respondents may over- or underreport behaviors and illnesses based on fear of social stigma or misunderstanding the question being asked. In addition, respondents may be prone to recall bias that is, they may attempt to answer accurately but remember incorrectly. Despite these limitations, most of the state or local self-report behavioral surveys (such as the BRFSS) benefit from large sample sizes and repeated administrations, enabling comparison over time. While the focus groups and interviews conducted for this study provide valuable insights, results are not statistically representative of a larger population due to non-random recruiting techniques and a small sample size. Strong efforts were made to engage a cross-section of individuals on all sides of this issue; however, it is possible that not all sides of the issue were represented. Lastly, it is important to note that data were collected at one point in time, so findings, while directional and descriptive, should not be interpreted as definitive. Cecil County, MD Substance Abuse Assessment 5

17 Percent CECIL COUNTY, MD SOCIAL AND ECONOMIC ENVIRONMENT The health of a population is associated with numerous factors. Who lives in an area certainly affects the overall community s health, but what services and resources are available in an area are also important. As discussed previously, risk and protective factors for substance abuse exist at all different levels individual, family, community, and society. The section below provides an overview of the population and social and economic environment of Cecil County. While age, income, and education are important characteristics that affect individual health, the distribution of these characteristics in a place may also have an impact on overall community health and the resources and services available. Age and Racial/Ethnic Composition of the Population Cecil County has seen an increase in population over the past two decades, though the age and racial makeup of the County have remained consistent. According to the U.S. Census, Cecil County had an estimated 101,696 people in The 2010 U.S. Census counted 101,108 people, up from 85,951 in Cecil County has undergone a transition in the past years, adding approximately 15,000 new residents since Stakeholders perceive the County as a haven for people moving from more urban areas, and viewed the County as being open to newcomers. As seen in Figure 3, when compared to neighboring counties, Cecil County has the highest percentage of children under 18, approximately 1 in 4 residents. The only geographic area that is slightly younger is Baltimore city. Data also show that the County has a small percentage of seniors, which is consistent with how participants described Cecil County. Figure 3: Age Distribution of Population by State, County, and City, <5 Years <18 Years 65 Years Maryland Cecil County Baltimore City Baltimore County Harford County Kent County Source: US Department of Commerce, Bureau of the Census, 2010 Census Cecil County is generally homogenous in its racial/ethnic composition and moreso than neighboring Harford and Kent Counties. According to the U.S. Census, Cecil County is 89.2% White and 6.2% Black/African American (compared to Harford County which is 81.2% White and 12.7% Black/African American, and Kent County which is 77.9% White and 14.7% Black/African American). Approximately 3.4% of Cecil County s population self-identifies as Hispanic/Latino (any race). Cecil County, MD Substance Abuse Assessment 6

18 Percent Unemployment, Income, and Poverty While Cecil County is an area of stark contrasts in income, limited local employment and a cycle of unemployment and poverty among young people are seen as leading to hopelessness and substance abuse in Cecil County. Unemployment data indicate how Cecil County has been hard hit by the economic downturn. The map below (Figure 4) shows the latest unemployment figures (March 2013) in Maryland, and indicates that outside of Baltimore City, Cecil County has some of the highest unemployment rates compared to its neighbors. The past five years have been extraordinarily challenging financially for residents in the County (Figure 5). The County has been disproportionately affected by the economic crisis in 2008, with the biggest jumps occurred during a four month period from November 2008 to February 2009 (respectively, unemployment rose monthly: 5.9% 7.0% 9.0% 9.5%). Figure 4: Unemployment Rate by County across Maryland, March 2013 Cecil County Source: US Bureau of Labor Statistics, 2013 Figure 5: Unemployment Rate by State and Cecil County, March 2003 March Maryland Cecil County Mar 2003 Mar 2004 Mar 2005 Mar 2006 Mar 2007 Mar Mar Mar Mar 2008* 2009* 2010* 2011* Mar 2012 Mar 2013 *Reflects model adjustment. Source: US Bureau of Labor Statistics, 2013 Cecil County, MD Substance Abuse Assessment 7

19 Median Household Income Unemployment rates are higher among younger populations, with 32.7% of year olds and 19.5% of years olds considered unemployed in (American Community Survey, 2011) There are not many jobs with high salaries, so there is a discrepancy between the haves and have nots. Social service provider We have both the poor and the very wealthy it s a place of the extremes. Community member There are lots of residents who are failing drug tests when they are trying to get jobs. It hurts the ability of the County to advance economically and reinforces the challenges for local business that they can t staff their businesses here. -Community leader Community stakeholders viewed the County as having a large population of unskilled or low-skilled workers. They also noted that while the recession has impacted the economy and caused stress for workers, numerous challenges exist around workforce development and increasing local business opportunities. Stakeholders stated that these challenges included the lack of highly skilled, drug-free workers, the low salaries of available employment, and retention of employees. Another issue is that county residents often commute outside the county for work, due to the lack of available jobs in the county. Residents viewed the lack of good employment and resulting poverty as perpetuating the high rates of substance abuse and crime. People don t have cars or money to spend on getting to a job. That s why we need employers in the county. The respondent continued by saying that the County was stuck on [wanting to be] rural, but with a growing population, you need to supply jobs or they ll have too much time on their hands, which leads to substance abuse problems. It was noted in discussions that the perceived lack of a qualified local workforce has impeded efforts to attract businesses to the County, as does the high rate of substance abuse. Several respondents mentioned that job training programs require people to be clean from using drugs, and the programs struggle to find people who qualify. Another issue is that the available jobs primarily target low-skilled workers, which some say has decreased motivation, since no one wants to do the dirty work. Now you have all these young people who don t want to work. While unemployment was a dominant theme in conversations during this study, median household income in the County falls in the middle of its neighbors. As seen in Figure 6, Cecil County had a median income of $66,903 in 2010, which is higher than the State of Maryland and Baltimore City, but comparable to neighboring counties. Figure 6: Median Household Income by State, County, and City, 2010 $100,000 $80,000 $60,000 $40,000 $20,000 $0 $40,100 Maryland $66,903 $40,100 Cecil County Baltimore City $65,411 Baltimore County $79,953 Harford County Source: US Department of Commerce, Bureau of the Census, 2010 Census $53,480 Kent County Cecil County, MD Substance Abuse Assessment 8

20 Percent Yet, the median income does not capture the extremes. While 28.8% of Cecil County s population has an income of $100,000 or more, 17% earn less than $25,000. Those that fall under the federal poverty level face even greater challenges. As seen in Figure 7, the percent of all people in poverty is lower for Cecil County (9.4%) than Maryland and Baltimore City, but higher than neighboring counties. iii Children under 18 in Cecil County experience higher rates of poverty than children in Maryland and most neighboring counties. Community stakeholders viewed Cecil County as primarily a poor, low-income community with pockets of affluence. However, they perceived that the cost of living in Cecil County was relatively low in comparison to nearby cities and towns. Figure 7: Percent of Population below Federal Poverty Level by State, County, and City, All < Maryland Cecil County Baltimore City Baltimore County Harford County Kent County Source: US Department of Commerce, Bureau of the Census, 2010 Census Community residents and providers indicated that household poverty and unemployment have left people stressed and anxious and overwhelmed, who then choose to self-medicate with drugs. One substance abuse treatment provider reported, Substance use helps people cope with the stress of life, adding that people with more resources learn a variety of coping mechanisms, not just drugs. Over time, individuals who are jobless feel hopeless and become increasingly despondent and circumstances drive them to use more heavily. Educational Attainment Despite good public schools, many students do not continue past high school, perpetuating the perception that residents do not value education. Low educational attainment is viewed as reinforcing low aspirations among young people and maintaining a lower level of economic prosperity among the population. Cecil County had a 4-year high school graduation rate of 84.1% in 2012, meaning 84.1% of entering 9 th graders graduated in 4 years. While the high school graduation rate in Cecil County has steadily increased over recent years (from 77.1% in 2009) and is consistent with Maryland overall (83.6% in 2012), it remains below neighboring counties. Individuals who do not finish high school are more likely than people who finish high school to lack the basic skills required to function in an increasingly iii The figure above represents the percentage of individuals and children who were living below the federal poverty level, which is adjusted for family size, for the past 12 months. For example, in 2010, the federal poverty level was $14,570 for a family of two and $22,050 for a family of four. Cecil County, MD Substance Abuse Assessment 9

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